Tweeting into back pain and reassuring yourself out of it.

Eight out of ten people will experience low back pain during their lives - and for some it can be disabling and last a long time.

Two researchers at Neuroscience Research Australia have been studying how to predict whether someone’s about to develop back pain by their tweeting, and what a GP should say to a person with back pain to reassure them.

Transcript

Norman Swan: Eight out of ten people will experience low back pain during their lives and for some it can be disabling and last a long time.

Two researchers at Neuroscience Research Australia have been studying how to predict whether someone's about to develop back pain by their tweeting, and what a GP should say to a person with back pain to reassure them?

In our Sydney studio we have James McAuley and Adrian Traeger.

Welcome to the Health Report.

Adrian Traeger: Thanks Norman.

James McAuley: Thank you.

Norman Swan: James, let's start with the tweeting story. What is the background to this?

James McAuley: Well, we know that people tweet about all sorts of things about their lives, and we also know that they tweet about their health conditions as well or what's happening to them. So we were interested in whether or not we could identify people in advance of a tweet about their back pain, whether we could identify them. So we conducted a large study…

Norman Swan: You're claiming it's the largest ever study of back pain. That's a tweet in its own right.

James McAuley: It is.

Norman Swan: 740,000 people.

James McAuley: Yes, and that was everybody who tweeted about back pain over a two-year period, but not just they tweeted about back pain, they had to tweet about back pain and then not tweet about that for a month prior to that. So we were calling this an acute tweet about back pain. And we were interested in what they were doing just prior to that. So the proximal determinant of that tweet is what we call it.

Norman Swan: So you are trying to identify tweets ahead of the tweet about back pain to see whether or not that predicted whether or not people get back pain compared to a control group?

James McAuley: Yes, well, not compared to a control group, actually compared within that person. So we use a design called the case crossover design, which has been used in epidemiological work to identify proximal determinants of accidents, for example, or of flu or of a cold. So we employed this method to try and identify the risks of tweeting about back pain.

Norman Swan: So very briefly, because we've got to get to Adrian in a minute about his study, but what did people tweet when they said they had back pain?

James McAuley: Yes, so we had these search terms and we tried to identify the tweets, and some of the tweets were like 'My back is killing me' or 'My back hurts like hell', 'Ugh, my back is killing me, stupid homework…' and then an expletive. Or 'I need a new computer, this seat hurts my back'. So there are all sorts of things that people talk about in relation to developing back pain.

James McAuley: Yes, that's right. So we trawled through all of the tweets that people made for over a two-year period. We employed a company to do this. They own the Twitter stream.

Norman Swan: You're kidding! So every one of my tweets goes into this Twitter stream?

James McAuley: Absolutely. And if you've had back pain then you will appear in this data.

Norman Swan: Okay. And how reliable is it? I keep my medical problems to myself, so how reliable do we know is saying 'I've got a bad back'?

James McAuley: Well, we try to identify people who have just talked about their back, so they used a personal pronoun. We also looked at subsequent tweets over the next two days and whether or not they tweeted about seeking some kind of healthcare, like paracetamol or…

Norman Swan: So you looked for corroboratory evidence.

James McAuley: Yes, exactly, and about 20% to 25% of people did.

Norman Swan: So what tweets in the month or so before…I think it was up to two months before the back pain tweet predicted whether or not you are going to get back pain?

James McAuley: So we were looking at proximal determinants, so that's just in the 48-hour period prior to the…

Norman Swan: I thought was longer than that.

James McAuley: No, we compared that period to the longer period. And in that 48 hours prior to the tweet about back pain, people who had a psychological risk factor, so they said they were fed up or they were angry or they felt a bit depressed, those people were about 30% more likely to tweet about back pain the next day.

Norman Swan: Right. And what about physical things like bending down and doing the garden?

James McAuley: Yes, we looked at those as well and those were predictive of back pain but less strongly predictive of back pain. Some of the things like general health conditions like 'I feel under the weather' or 'I'm not feeling very well', they are even less associated with back pain.

Norman Swan: And twice as many women as men, and about 300,000 people didn't identify their gender at all.

James McAuley: Yes, that's right.

Norman Swan: So how useful is this? What are you going to do with it?

James McAuley: Well, I think what the study shows is that we can identify people in advance of them tweeting about their back pain. Now, what we do about that we have to think about because we could develop a health intervention to target people before they tweet about their back. But there are ethical hurdles, as I'm sure you can imagine, associated with that, by targeting individuals…

Norman Swan: Intervening with destiny.

James McAuley: That's right, yes.

Norman Swan: So, interesting findings. How you use it is another matter. And you just take a deep breath on the fact that somebody owns all your tweets.

James McAuley: That's right.

Norman Swan: Adrian Traeger, you looked at the role of reassurance in people who've got a really bad back.

Adrian Traeger: Yes, I did. So our study was really looking at what's an effective intervention to really reassure a patient in the doctor's surgery.

Norman Swan: Nothing to do with tweets, these are real people, real clinicians, you know what their gender is, et cetera.

Adrian Traeger: That's right. So we are really interested in this concept of reassurance because all the clinical guidelines recommend that as a number one strategy for treating low back pain, which is to reassure your patient, to remove their fear and concern. And so the trouble with that is that we don't really know how to do that best. The most common way is to probably provide a scan, which we know is not helpful for patients with back pain.

Norman Swan: It could make them more anxious because it shows all sorts of dreadful things which don't mean anything.

Adrian Traeger: That's right, yes, and we know that it can lead to poor outcomes as well. So we thought the alternative was what else can you do to put a patient's mind at ease? And we really wanted to look at patient education.

Norman Swan: And you studied the available research in the area and I think came up with about 14 trials which looked at this. And what did you find?

Adrian Traeger: Yes, so we were able to combine the results of 12 randomised control trials which included over 3,000 patients. And what we found was that a very brief intervention at the doctor's office for as little as five minutes could reassure patients for up to a year.

Norman Swan: And what was said in that consultation?

Adrian Traeger: We did look at that. So most of the studies used are what's called a biopsychosocial education model, which is to explain to the patient that there are factors in your back that are affecting the pain, but also what you are thinking and what you are feeling also contribute to the problem.

Norman Swan: Right. But it's not all in your head.

Adrian Traeger: No, no…

Norman Swan: That would not reassure people at all.

Adrian Traeger: Well, it's funny you should say that. I suppose we are very interested in the role of the brain and we are looking at a different education model on the back of this review which looks at explaining to patients the role of the brain in back pain, and we are awaiting the results of our own randomised control trial on that.

Norman Swan: And briefly, you found that doctors were more…if it came from the doctor it was better than coming from the physio or the nurse.

Adrian Traeger: Yes, that was probably the saddest result given that I'm a physiotherapist…

Norman Swan: People don't believe you.

Adrian Traeger: Yes, that's right, we need to do something to boost our credibility I think. But GPs were really well placed to provide this education…

Norman Swan: And what was the net effect? Did it mean that they didn't have a back scan? Did it mean that they didn't come back for more care? What good did it do?

Adrian Traeger: Well, they were less worried and less fearful about the problem and they didn't come back for as many visits to the doctor. So we found although it wasn't a direct comparison we found equivalent effects to sending someone for a scan. So to reduce one primary care visit to the doctor, the number needed to treat or the number needed to intervene with education was 12.

Norman Swan: Which is quite good actually by treatment standards.

Adrian Traeger: That's right.

Norman Swan: Thank you very much to you both, to Adrian Traeger and James McAuley, both of Neuroscience Research Australia.